July/ 2022

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

BACTERIAL SKIN INFECTIONS
ICD-10-L01, L73.9, L08, L02, L03, A46, L00
Skin hygiene, advise on 1. IMPETIGO
handwashing/ local hygiene, CLINICAL FEATURES
avoidance of oil application, Wet yellow brown crusts overlying red inflamed skin
adequate nutrition • Types Non bullous (NBI; commoner), bullous (BI)
For recurrent/ severe lesions: • Affected age group usually children
GENERAL evaluate for nasal carriage, • Common sites Face (perinasal, perioral) > extremities; extensive
diabetes, underlying skin with scabies/ atopic eczema
PRINCIPLES OF conditions (scabies, atopic
MANAGEMENT dermatitis)
MANAGEMENT
In immunocompromised/ • Topical antibiotics for 5 days
diabetics: consider the need • Oral antibiotics for extensive involvement or numerous lesions,
for gram negative coverage lymphadenopathy or in outbreaks to prevent transmission

2. ECTHYMA 3. FOLLICULITIS
CLINICAL FEATURES CLINICAL FEATURES MANAGEMENT
• Black thick crust (eschar) with underlying ulcer Hair follicle centred pustule/ papule • Topical antibiotics for 5 days
& surrounding redness & edema Rule out non bacterial causes: oils, chemicals, • Oral antibiotics for multiple
MANAGEMENT waxing, epilation, occlusive dressing lesions
• Treat with oral antibiotics for 7 days RECURRENT FOLLICULITIS Recurrent infection or
• Anti-inflammatory: Paracetamol
• Gentle crust removal may be attempted after outbreak in multiple members of family may
soakage with sterile saline; topical antibiotics indicate nasal Staphylococcus aureus 500mg/ Ibuprofen 400mg SOS
over the exposed ulcer carriage or human-pet transmission for pain relief

4. FURUNCLE 5. CARBUNCLE 6. CUTANEOUS ABSCESS

CLINICAL FEATURES Painful follicle centric CLINICAL FEATURES Confluence of multiple closely CLINICAL FEATURES Painful, warm, red
nodule/ pus point/ impending bulla/ spaced furuncles + pus draining from multiple fluctuant skin swelling
ulcer with marked surrounding follicular orifices
erythema, edema and induration Commonly nape of neck> breasts, buttocks in
uncontrolled diabetes
LARGE
SMALL

INCISION AND DRAINAGE HOSPITALIZATION AND IV TREATMENT FOR

• Oral antibiotics + • Incision and drainage/ debridement
MANAGEMENT

SEVERELY ILL PATIENTS

• Topical antibiotics: • Ancillary antibiotics if systemic • Inj Ceftriaxone 2g BD OR Inj
to reduce inflammatory signs, associated septic Amoxicillin-clavulanate 1.2gm TDS
contamination of phlebitis, multiple/ large abscesses,
• Alternatively - Inj Clindamycin
surrounding skin prominent cellulitis &
immunocompromised state 600-900mg TDS

IMPETIGO ECTHYMA FOLLICULITIS FURUNCLE CARBUNCLE

7. CELLULITIS 8. ERYSIPELAS
CLINICAL FEATURES Acute spreading CLINICAL FEATURES A more superficial, bright red, edematous, painful
infection of skin involving subcutaneous area with a clear demarcated edge; common sites: lower
tissue; Painful, red, tender, diffuse extremities>face. Often associated with lymphangitis and
swelling mostly involving the limbs lymphadenopathy; broken skin/ portal of entry may be visualised CELLULITIS WITH BULLAE

MILD MODERATE SEVERE

• Typical cellulitis/ erysipelas • Typical cellulitis/ erysipelas with With poor response to oral antibiotics,
with no focus of purulence immunocompromised, signs of deeper
CATEGORIZE DISEASE SEVERITY

systemic signs of infection

MANAGEMENT infection like bullae, skin sloughing or
• Outpatient treatment with oral MANAGEMENT
systemic signs of infection like hypotension,
antibiotics Hospitalization and parenteral or with organ dysfunction
MANAGEMENT

• Elevation of affected area (to antibiotics: MANAGEMENT

allow for dependent drainage); • Inj Ceftriaxone 2g BD OR Empiric broad spectrum IV antibiotic
treatment of predisposing Inj Amoxicillin-clavulanate 1.2gm coverage
factors TDS • Vancomycin + Piperacillin/ tazobactum
• Anti-inflammatory (Ibuprofen • Surgical debridement
• Alternatively (allergic to penicillins)
400mg BD, Indomethacin • Sensitivity profile based modification of
75mg BD) Inj Clindamycin 600-900mg IV TDS antibiotics
INVESTIGATIONS COMPLICATIONS
1. Swabs for gram staining and pus culture are desirable Subcutaneous abscesses, blistering
2.Blood cultures and biopsies are not routinely recommended, but useful with co-morbid (often haemorrhagic), ulceration,
conditions (malignancy on chemotherapy, immunocompromised states, animal bites etc.) tissue necrosis, myositis, septicemia

9. STAPHYLOCOCCAL SCALDED SKIN SYNDROME RED FLAGS

• Superficial peeling of skin due to toxin producing strains of staphylococcus • Temperature >100.4 ºF,
• Starts as tender and warm erythema and progresses to localised or generalised WBC>12,000 or < 4000/μL, heart
exfoliation with fever, malaise +/- dehydration and electrolyte disturbances rate > 90 bpm, or respiratory rate
• Follows a local staphylococcal infection of either skin, throat, nose, umbilicus, or gut > 24/min may indicate sepsis
• Bacteria cannot be demonstrated from blisters (cultures from original site may be • Severe pain followed by deceptive
positive) absence may indicate necrotising
• Treatment: preferably in-patient fasciitis
• Mild cases: oral anti-staphylococcal antibiotics; severe cases: IV antibiotic • Dark discoloration of overlying
• Consider methicillin resistant Staphylococcus aureus (MRSA) coverage skin
• Usually remits within a week in children, high mortality in adults

PHARMACOTHERAPY
FOR NASAL CARRIERS IN ALL PATIENTS SUSPECT THE NEED FOR MRSA COVERAGE IF:
ANTIBIOTICS FOR SKIN AND SOFT TISSUE INFECTIONS
2% Mupirocin ointment • Poor immune status
• Severe systemic signs
for 5 days a month
IF ALLERGIC TO • MRSA infection elsewhere
PREFER β-LACTAMS
• If no improvement in 48-72 hours
• Amoxycillin 500mg TDS PENICILLINS TOPICAL
• Penetrating trauma
(25-50 mg/kg/day) • Erythromycin ANTIBIOTICS
• Cloxacillin 500mg QID 500mg QID (40 • Mupirocin ORAL ANTIBIOTICS FOR SUSPECTED IV ANTIBIOTICS FOR MRSA
(50mg/kg/day) mg/kg/day) cream 2% OR CONFIRMED MRSA INFECTION • Vancomycin: 15 mg/kg BD
• Cephalexin 250-500mg • Clindamycin: • Fusidic acid • Cotrimoxazole 2 DS tablets BD
• Linezolid: 600 mg BD
QID (25–50 mg/kg/day) 300-600mg cream 2% • Doxycycline 100 mg BD
• Clindamycin: 600-900 mg
• Amoxicillin clavulanate BD/TID • Framycetin • Minocycline 100 mg BD TDS
combination: 625mg TDS (20mg/kg/day) cream 1% • Linezolid 600 mg BD
ANTIBIOTIC SUSCEPTIBILITY PATTERNS MAY VARY WITH REGION AND TIME
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.